Louisiana Medicaid Long-Term Care Application Packet

LOUISIANA MEDICAID LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Cover Letter to LDH Medicaid
2. Applicant and Household Information
3. Program Selected
4. Citizenship, Identity, and Residency Verification
5. Income Disclosure
6. Resource (Asset) Disclosure
7. Primary Residence and Home-Equity Treatment
8. 60-Month Look-Back Disclosure of Transfers
9. Spousal Impoverishment Worksheet
10. Qualified Income Trust (Miller Trust) Certification
11. Authorized Representative Designation
12. Medical Necessity / Level-of-Care Documentation
13. Applicant Certification and Signature
14. Document Index
15. Louisiana Practice Notes
16. Sources and References

1. COVER LETTER TO LDH MEDICAID

Date: [__/__/____]

Louisiana Department of Health
Medicaid Eligibility Operations
P.O. Box 91278
Baton Rouge, LA 70821-9278

Re: Application for Long-Term Care Medicaid
Applicant: [APPLICANT FULL LEGAL NAME]
Date of Birth: [__/__/____]
Social Security No.: *--[____]
Medicaid ID (if any): [________________________________]

Dear Eligibility Specialist:

Enclosed please find the Medicaid application of [APPLICANT NAME] for [Nursing Facility / Community Choices Waiver / Adult Day Health Care Waiver / Long-Term Personal Care Services] benefits. The application includes income and resource verifications, the spousal-impoverishment worksheet, the 60-month transfer disclosure, and [if applicable] the executed Qualified Income Trust pursuant to 42 U.S.C. § 1396p(d)(4)(B).

I respectfully request a determination within the 45-day federal benchmark (90 days where a disability determination is required). Please direct all correspondence to the undersigned authorized representative.

Sincerely,

[________________________________]

[AUTHORIZED REPRESENTATIVE / ATTORNEY]

2. APPLICANT AND HOUSEHOLD INFORMATION

3. PROGRAM SELECTED

Mark all that apply:

• ☐ Nursing Facility (Long-Term Care) Medicaid — institutional care in a Medicaid-certified nursing facility.
• ☐ Community Choices Waiver (CCW) — HCBS alternative to nursing facility care for adults 65+ or 21+ with adult-onset disability who meet Nursing Facility Level of Care (NFLOC) under the interRAI-HC assessment.
• ☐ Adult Day Health Care (ADHC) Waiver — daytime services in licensed ADHC centers for adults 22+ at NFLOC.
• ☐ Long-Term Personal Care Services (LT-PCS) — in-home assistance with activities of daily living for Medicaid-eligible adults at NFLOC.
• ☐ PACE (Program of All-Inclusive Care for the Elderly) — for participants in PACE service areas.

4. CITIZENSHIP, IDENTITY, AND RESIDENCY VERIFICATION

Attach the following:

• ☐ Birth certificate, U.S. passport, naturalization certificate, or qualified-immigrant documentation.
• ☐ Government-issued photo identification.
• ☐ Proof of Louisiana residency (utility bill, lease, voter registration, or LA driver's license).
• ☐ Social Security card.
• ☐ Medicare card (Parts A/B/D), if enrolled.
• ☐ Other health insurance cards.

5. INCOME DISCLOSURE

List ALL gross monthly income (before deductions) of applicant and, if married, of spouse. Attach award letters, pay stubs, pension statements, and bank-deposit records.

Income-Cap Analysis (verify current cap with LDH at filing):

• Per the Special Income Limit (300% of the SSI federal benefit rate) used in Louisiana for institutional and HCBS-waiver Medicaid, the 2026 income cap is approximately $2,982/month for an individual applicant.
• ☐ Applicant's gross income is AT OR BELOW the income cap. No QIT required.
• ☐ Applicant's gross income EXCEEDS the income cap. A Qualified Income Trust ("Miller Trust") MUST be established and funded each month before eligibility can attach (see Section 10).

6. RESOURCE (ASSET) DISCLOSURE

List ALL countable and non-countable resources held individually or jointly by applicant and spouse on the first moment of the first day of the month of application.

Asset-Limit Analysis (verify current limits at filing):

• 2026 individual LTC asset cap: $2,000.
• 2026 Community Spouse Resource Allowance (CSRA) maximum: $162,660 (federal maximum; verify Louisiana's current floor and ceiling).
• ☐ Countable resources are AT OR BELOW the limit.
• ☐ Resources EXCEED the limit; spend-down or restructuring plan attached.

7. PRIMARY RESIDENCE AND HOME-EQUITY TREATMENT

Equity-Cap Analysis (verify current cap at filing):

• 2026 federal home-equity limit (states using federal floor): $752,000. Applicants with home equity in excess of this cap are ineligible for LTC Medicaid unless a spouse, minor child, or blind/disabled child resides in the home (42 U.S.C. § 1396p(f)).
• ☐ Equity is below the cap.
• ☐ Equity exceeds the cap; statutory exception applies. Specify: [________________________________]

Intent to Return Home: Applicant [is / is not] retaining the residence as exempt subject to a written intent-to-return statement. See attached affidavit if institutional placement is anticipated to last six months or longer.

8. 60-MONTH LOOK-BACK DISCLOSURE OF TRANSFERS

Disclose every transfer of an asset for less than fair-market value made by the applicant or spouse during the 60 months immediately preceding the application date. This includes gifts, sales below FMV, additions to joint accounts, irrevocable-trust funding, and forgiveness of debt.

Recognized Exceptions (42 U.S.C. § 1396p(c)(2)):

• ☐ Transfer to a spouse or to a third party for the sole benefit of a spouse.
• ☐ Transfer to a blind or disabled child.
• ☐ Transfer to a (d)(4)(A) special-needs trust for a disabled person under age 65.
• ☐ Transfer of homestead to a "caretaker child" who lived in the home and provided care for at least two years prior to institutionalization.
• ☐ Transfer of homestead to a sibling with an equity interest who lived in the home for at least one year prior to institutionalization.
• ☐ Transfer made exclusively for a purpose other than to qualify for Medicaid.
• ☐ Return of transferred asset (cures the transfer in full).

Penalty Calculation (verify current Louisiana transfer-penalty divisor at filing):

• Total uncompensated transfers: $ [____]
• Current LDH transfer-penalty divisor (statewide average monthly private-pay nursing-facility cost): $ [____]
• Penalty period (months) = uncompensated value ÷ divisor = [____] months.
• Penalty period BEGINS on the later of (a) the date of transfer or (b) the date the applicant is otherwise eligible for LTC Medicaid and would be receiving institutional-level care but for the transfer. La. Admin. Code tit. 50.

9. SPOUSAL IMPOVERISHMENT WORKSHEET

(Complete only if applicant is married and spouse is not also institutionalized.)

10. QUALIFIED INCOME TRUST (MILLER TRUST) CERTIFICATION

Required only if applicant's gross monthly income exceeds the LTC income cap.

I, [APPLICANT NAME], hereby certify:

1. A Qualified Income Trust has been established under 42 U.S.C. § 1396p(d)(4)(B) and Louisiana law on [__/__/____], identified as the [TRUST NAME] dated [__/__/____].
2. The trust is irrevocable and contains only the income (and accumulated interest thereon) of the applicant. No countable resources have been deposited.
3. The State of Louisiana (Louisiana Department of Health) is named as the residual beneficiary up to the total amount of Medicaid benefits paid on behalf of the applicant.
4. The trustee is [TRUSTEE NAME], address [________________________________], who is not the applicant.
5. The trust is funded each calendar month by depositing the portion of the applicant's gross monthly income that exceeds the LTC income cap, and disbursements are limited to: (a) the personal needs allowance; (b) the spousal-maintenance allowance, if any; (c) Medicare and other health-insurance premiums; and (d) the patient-liability share to the facility/waiver provider.
6. A copy of the executed trust instrument and the trust account-funding records are attached.

[________________________________]

[APPLICANT / TRUSTEE]

11. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [APPLICANT NAME], designate [REPRESENTATIVE NAME] as my authorized representative pursuant to 42 C.F.R. § 435.923 to act on my behalf in this Medicaid application, including the receipt of notices, submission of evidence, attendance at interviews, and pursuit of administrative appeals.

Authorized representative contact:

• Name: [________________________________]
• Relationship: [Attorney / Family / Power of Attorney / Curator / Tutor]
• Address: [________________________________]
• Phone: [________________________________]
• Email: [________________________________]

[________________________________]

[APPLICANT SIGNATURE] Date: [__/__/____]

12. MEDICAL NECESSITY / LEVEL-OF-CARE DOCUMENTATION

Attach the following to support Nursing Facility Level of Care (NFLOC) determination:

• ☐ Form 90-L (Medical Eligibility for Nursing Facility / Waiver) signed by attending physician within 90 days of application.
• ☐ Recent history and physical (within 90 days).
• ☐ Medication list and physician orders.
• ☐ Hospital discharge summary (if institutionalized).
• ☐ interRAI-HC or interRAI-LTCF assessment results, if available.
• ☐ Functional/cognitive assessment (e.g., ADL/IADL deficits, MMSE, MoCA).
• ☐ Diagnosis list with ICD-10 codes.

13. APPLICANT CERTIFICATION AND SIGNATURE

I declare under penalty of perjury under the laws of the State of Louisiana and the United States that the information provided in this application and accompanying documentation is true, correct, and complete to the best of my knowledge. I understand that:

• Knowingly providing false information is a felony under federal law (42 U.S.C. § 1320a-7b) and Louisiana law (La. R.S. § 14:70.1) punishable by fine and imprisonment.
• LDH may verify the information through electronic data matches, third-party contacts, and field investigations.
• I must report any change in income, resources, household composition, address, or living arrangement within ten (10) days of the change.
• LDH may pursue estate recovery against my probate estate after my death up to the amount of long-term-care Medicaid benefits paid on my behalf if I am 55 or older when benefits are received.

Applicant signature: [________________________________]

[APPLICANT NAME] Date: [__/__/____]

Authorized representative signature: [________________________________]

[REPRESENTATIVE NAME] Date: [__/__/____]

14. DOCUMENT INDEX

15. LOUISIANA PRACTICE NOTES

• Income cap state. Louisiana applies a hard 300%-FBR income cap to nursing-facility and HCBS-waiver Medicaid. The ONLY way for an over-cap applicant to qualify is a properly drafted, funded, and administered Qualified Income Trust under 42 U.S.C. § 1396p(d)(4)(B) (the "Miller Trust"). Failure to fund the QIT in any given month results in loss of eligibility for that month.
• HCBS Waiver waitlist. The Community Choices Waiver and Adult Day Health Care Waiver are slot-limited Section 1915(c) programs administered by OAAS. Register on the Request for Services Registry (RFSR) early via Louisiana Options in Long-Term Care (1-877-456-1146); financial eligibility cannot be acted on until a slot is offered.
• Civil-law property quirks. Louisiana is the only U.S. civilian-property jurisdiction. Community-property characterization, usufruct/naked-ownership splits, donations inter vivos under La. C.C. arts. 1467 et seq., and forced-heirship rules can interact with Medicaid transfer and estate-recovery rules in ways that differ materially from common-law states. Louisiana counsel review is essential.
• Estate recovery. LDH's Medicaid Estate Recovery Program asserts claims against the probate succession of recipients age 55+ for LTC services received. Hardship waivers and the homestead-residing-relative defense are available. Plan recovery defenses in advance of application where possible.
• Continuing care retirement community (CCRC) entrance fees. DRA-2005 treats certain CCRC entrance fees as countable resources to the extent refundable (42 U.S.C. § 1396p(g)). Disclose any CCRC contract.
• Promissory notes and personal services contracts. Subject to actuarially sound, non-cancellable, and non-assignable requirements under 42 U.S.C. § 1396p(c)(1)(I); document fair-market value of services rendered to avoid uncompensated-transfer treatment.
• Appeals. Adverse determinations are appealable to the LDH Division of Administrative Law within 30 days of the notice of decision. Continuation-of-benefits pending appeal is available if the appeal is filed within ten days for terminations/reductions.

16. SOURCES AND REFERENCES

• 42 U.S.C. §§ 1396, 1396a, 1396p — Federal Medicaid Act
• 42 U.S.C. § 1396p(d)(4)(B) — Qualified Income Trust (Miller Trust)
• 42 U.S.C. § 1396p(c) — Transfer-of-asset rules and penalty
• 42 U.S.C. § 1396p(f) — Home-equity cap
• 42 C.F.R. § 435 et seq. — Federal Medicaid eligibility regulations
• La. R.S. § 46:153 et seq. — Louisiana Medical Assistance Program
• La. R.S. § 46:1051 et seq. — OAAS authority
• La. Admin. Code tit. 50, Parts III, XXI, et seq. — Louisiana Medicaid rules
• LDH Medicaid Eligibility Manual — https://ldh.la.gov/medicaid/
• LDH Medicaid online portal — https://medicaid.ldh.la.gov/
• LDH Medicaid Customer Service Unit — 1-888-342-6207
• OAAS Community Choices Waiver — https://ldh.la.gov/office-of-aging-and-adult-services/community-choices-waiver-ccw
• OAAS Adult Day Health Care Waiver — https://ldh.la.gov/office-of-aging-and-adult-services/ADHC-waiver
• Louisiana Options in Long-Term Care — 1-877-456-1146
• CMS Spousal Impoverishment standards (annual) — https://www.medicaid.gov/medicaid/eligibility-policy/medicaid-eligibility-aged-blind-disabled/spousal-impoverishment/
• DRA 2005 (Pub. L. 109-171) — Annuity, transfer, and home-equity reforms

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Louisiana attorney must review and customize this packet before submission. Medicaid figures change annually — verify all dollar limits, divisors, and statutory citations against the LDH Medicaid Eligibility Manual current as of the application date.